In his opening speech, in February 2021, for public inquiry into some of the deaths that occurred in CHSLDs during the COVID-19 pandemic, coroner Géhane Kamel promised himself to “make recommendations to purpose of preventing further deaths.
After collecting 220 factual testimonies and consulting dozens of documents, the coroner compiled two dozen, from the Government of Quebec, the Ministry of Health and Social Services (MSSS), the CISSS and CIUSSS and the doctors of the Collège des Quebec (see box below).
The coroner first took as a lesson from the pandemic that the national director of public health should have real independence from power, which would not happen, he believed, because it was as Deputy Ministers that Horacio Arruda and Luc Boileau were mixed hold position. .
One of its first recommendations, contained in the investigation report of which Radio-Canada obtained a copy, was aimed at examining the role of the national director of public health so that his or her duties can be performed with complete independence and without political interference .
In the coroner’s view, these two duties are different and may be incompatible.
For example, he wanted some public health instructions, at the start of a pandemic, specifically on wearing a mask that is not mandatory in CHSLDs.
Is that also his opinion if he is [Horacio Arruda] don’t have to worry about possible stock shortages? I often think not. Therefore, in my humble opinion, the risk of wearing two hats.
With the expression dear to former director of public health Horacio Arruda in the plane built in the middle of flight said the coroner that a flight plan, radar or other flight instruments, providing real-time information, should be a top priority [avec] an international scientific watch worthy of the name .
In his report, the coroner also mentioned, on several occasions, the absence of doctors in CHSLD, the first weeks of the pandemic, and their frequent use of teleconsultation.
” For one coroner, that so many residents died without the right to see a doctor in their last illness is not only sad, but distressing. “
According to him, “it is almost unthinkable that life or death decisions can be made based on a telephone relay alone”.
The coroner made a recommendation to the College of Physicians to review the individual medical skills of the visiting physicians of CHSLD Herron, Moulin and Sainte-Dorothée, specifically with regard to their decision to continue teleconsultation care despite the need for support and the sheer number of deaths .
This recommendation may open the door to possible ethical errors for some physicians.
Doctors then volunteered at CHSLDs in mid -April 2020, following a call for help from the Prime Minister.
The coroner also recommends checking with health care establishments the necessary supervision that justifies the use of anxiety and palliative sedation protocols in an acute care setting .
Radio-Canada reported in February on doses potentially excessive associated with respiratory distress protocols for patients with COVID-19.
Marguerite Blais survived
One of the testimonies expected at the hearings was that of the Minister responsible for Seniors and Carers, Marguerite Blais.
His testimony has undoubtedly allowed us to better understand the date on which everything really measures the coming crisis, around March 9, 2020. , said Coroner Kamel. This is the most convincing testimony despite the speech formatted for this investigation. “
Prior to March 9, the minister’s involvement in crisis management was anecdotal […] once put in the loop, the contribution of the minister and his deputy minister is undeniable he added.
In the first wave, nearly two-thirds of the 5,688 COVID-19-related deaths occurred in CHSLDs. The journalist’s update Newspaper Aaron Derfel’s multiple deaths at private CHSLD Herron on April 10 fueled people’s anger and led to the launch of a coroner’s public inquiry.
The CEO of CIUSSS of West Montreal skinned
Several times in the report, the CEO of CIUSSS de l’Ouest-de-l’Île-de-Montréal, Lynne McVey, was selected for her management of CHSLD Herron.
The coroner describes, for example, not good to look at the CEO blames CHSLD owners for moving residents to a hospital center “even if, in an emergency, this action is the most sensible if we want these residents to have a chance to get stuck here “.
He calls back the disorganization of the CIUSSS management team and points that out most deaths occurred when CIUSSS was already managing CHSLD .
The coroner recommends this MSSS ensuring greater accountability of CISSS/CIUSSS and MSSS managers .
He recommends converting fast private CHSLDs to private CHSLDs under agreement to improve funding.
The Legault government has been toying with the idea for more than two years.
There is no commission of inquiry, but …
During the coroner’s hearings and revelations to the media, the three opposition parties in 2021 jointly requested that the Coalition avenir Québec (CAQ) government conduct an independent public commission of inquiry into pandemic management in CHSLDs.
The coroner does not make a recommendation like this, but invites the government, in its conclusion, to make retrospective of events by vehicle that he thinks are appropriate to be carried out among other things, in the hierarchy of decisions, in the agility of the health system in times of crisis, in understanding and implementing responsibilities within the Ministries of Health, Seniors and Carers as well as within CIUSSS and CISSS .
An excerpt from the report praises the local work of CIUSSS de la Mauricie-et-du-Center-du-Québec, which contacted each of the 44 families affected by the death of a loved one in CHSLD Laflèche to offer them support and compassion.
Review the training of nurses
Another MSSS recommendation, check technical training so that CHSLD nurses and, if appropriate, auxiliary nurses perform the procedures necessary for primary care (respiratory care, venous and subcutaneous access, use of volumetric pumps, etc.) .
This recommendation is reminiscent of the will of the Order of Nurses of Quebec (OIIQ) for the next generation of health care professionals to obtain a university degree.
The 23 recommendations of coroner Géhane Kamel
That the Government of Quebec:
Review the role of the national director of public health so that his or her duties can be performed with full independence and without political impediment.
Examine the possibility of setting up a voluntary civic emergency service supervised by the Ministry of Public Security, as is sometimes seen in the event of a natural disaster.
Quickly review the service offer for our seniors by converting all private CHSLDs to private CHSLDs under the agreement.
Increases the offer of home support services for our seniors.
Ensures an inclusive policy in times of crisis to allow at least two carers to visit the host in a safe manner.
Implement safe healthcare professional/resident ratios in CHSLDs.
Increase, when necessary, the number of managers in CHSLD to ensure all shifts are covered (night and night assigned power).
Provide discussions with union bodies to review or add, as appropriate, collective agreement clauses that allow for increased availability and relief of staff during a health emergency.
Planning new infrastructure or renovation of residential environments by ensuring that the environments can meet requirements in terms of health care, especially in times of health crisis.
Ensures that residential facilities can offer individual rooms to residents.
That the Department of Health and Social Services:
Introduces the precautionary principle at the heart of any risk assessment and management process.
Ensures greater accountability of CISSS/CIUSSS and MSSS managers regarding care provided to seniors with loss of autonomy through monitoring indicators and an obligation to intervene in the event of quality care problems.
Be sure to maintain the necessary supply of protective equipment at all times in addition to planning reserves to meet needs in the event of a crisis.
Determine what comfort care facilities in CHSLDs should be offered at least.
Establish a national plan to equip all CHSLDs with the necessary equipment to provide this care.
Review technical training so that CHSLD nurses and, where appropriate, auxiliary nurses can perform the procedures necessary for primary care (respiratory care, venous and subcutaneous access, use of volumetric pumps, etc. )
Develop a tool with scenarios so that residents and/or their carers fully understand the implications of choosing the level of care.
Ensures management of CHSLDs combines a responsible manager, a nursing care directory and a medical directory.
That the CISSS and CIUSSS:
Make sure CHSLDs have an adequate presence of nurses who specialize in PCI so that they are present in day-to-day operations and that they ensure their maintenance.
Be sure to plan simulations in accordance with pandemic plans every three years.
Offer training in the keeping of medical records and perform periodic follow-ups.
Ensure necessary supervision that justifies the use of anxiety and palliative sedation protocols in an acute care setting.
That the College of Physicians of Quebec:
Examine the individual medical skills of the incoming physicians at CHSLD Herron, des Moulin and Sainte-Dorothée, specifically with regard to their decision to continue teleconsultation care despite the need for support and the sheer number of deaths.
Source: Radio-Canada
